How are physicians delivering palliative care? A population-based retrospective cohort study describing the mix of generalist and specialist palliative care models in the last year of life

Abstract

Background:To enable coordinated palliative care delivery, all clinicians should have basic palliative care skill sets (‘generalist palliative care’). Specialists should have skills for managing complex and difficult cases (‘specialist palliative care’) and co-exist to support generalists through consultation care and transfer of care. Little information exists about the actual mixes of generalist and specialist palliative care.Aim:To describe the models of physician-based palliative care services delivered to patients in the last 12 months of life.Design:This is a population-based retrospective cohort study using linked health care administrative data.Setting/participants:Physicians providing palliative care services to a decedent cohort in Ontario, Canada. The decedent cohort consisted of all adults (18+ years) who died in Ontario, Canada between April 2011 and March 2015 (n = 361,951).Results:We describe four major models of palliative care services: (1) 53.0% of decedents received no physician-based palliative care, (2) 21.2% received only generalist palliative care, (3) 14.7% received consultation palliative care (i.e. care from both specialists and generalists), and (4) 11.1% received only specialist palliative care. Among physicians providing palliative care (n = 11,006), 95.3% had a generalist palliative care focus and 4.7% a specialist focus; 74.2% were trained as family physicians.Conclusion:We examined how often a coordinated palliative care model is delivered to a large decedent cohort and identified that few actually received consultation care. The majority of care, in both the palliative care generalist and specialist models, was delivered by family physicians. Further research should evaluate how different models of care impact patient outcomes and costs.

Early experience with medical assistance in dying in Ontario, Canada: a cohort study

“…4 Our data do not support or refute either position, but as in other jurisdictions where MAiD is legal, we found that most MAiD recipients were followed by a palliative care clinician before death, 14,15,21,25 whereas only a minority of Ontario residents are followed by palliative care clinicians before they die. 26 This may allay fears that people are turning to MAiD because they cannot access palliative care. It may also suggest that people may be seeking MAiD to alleviate a type of suffering (e.g., existential distress 27 ) that may not be effectively treated by palliative care clinicians.…”

IDentification of patients in need of general and specialised PALLiative care (ID-PALL©): item generation, content and face validity of a new interprofessional screening instrument.

“…General PC concerns all patients who have a life-threatening disease or who are at the end of life without complex bio-psycho-socio-spiritual issues. These patients may be cared for by healthcare professionals with basic knowledge of PC (55,56). General PC includes breaking bad news, relief of pain and other symptoms, establishing goals of care, and supporting patients and relatives throughout the continuum of care (6,47,57).…”

IDentification of patients in need of general and specialised PALLiative care (ID-PALL©): item generation, content and face validity of a new interprofessional screening instrument.

“…General PC may concern up to 80% of the proportion of patients requiring PC (2). Specialised PC is for patients whose clinical situations are complex and/or unstable, and associated with high level of suffering of the patients and/or their relatives (55,56,58). Specialised PC and treatments should be provided by an interprofessional team, including physicians, nurses, psychologists, social workers, and spiritual assistants, who are specifically trained in PC (47, 57).…”